35 YEAR OLD FEMALE WITH YOUNG ONSET HYPERTENSION
May 04, 2023
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan
CHEIF COMPLAINTS:
38 years old female housewife resident of Cooch,BiharComplains of lowerback ache since one year
Patient came for the excision of keloid over
ear lobe
Born in Meghalaya in 1983 by normal delivery. Milestones achieved normal.
Education - 10th standard
Patient was apparently asymptomatic until 18 years ago
She complains of headache at parietal region throbbing pain insidious onset radiating to neck and hands phonophobia present along with lacrimation of eyes. Anger outburst at that time. No complains of nausea or vomitings, headache during sleep, diplopia . Aggreviated in summers relives on taking medication saradon.
18 years ago she had closure of ear piercings and pain on forcefully wearing ear rings.
Complains of pain in right calf since 15 years after strenuous exercise relives automatically. Did not affect her daily routine activities. Pain aggreviates in cold condition and relives after applying Ayurvedic oil locally
Complains of elbow joint pains, shoulder joint, knee joint, heel joint and distal interphalangeal joints stiffness in the early mornings during winters.
Patient had insomnia and frequent headaches, bleeding from mouth and nose 7 years ago,went to local hospital BP systolic -240 got diagnosed with hypertension. Prescribed telma am 40/5mg changed to tab telma 40mmhg since 2 years.
Complains of belchings and vomitings accompanied with headache, sweating and palpitations, feels weak and hot three years ago aggreviated at evenings and nights relives after taking eno and drinking sprite.
Patient had body pains and giddiness and increased sleepiness. Got sugar profile tested at home. Drank guava leaf juice and symptoms relived.
Left lower back pain dragging type insidious onset radiating till left foot since one year aggreviated at nights on lying supine or on standing and relives automatically by morning.
Patient is known case of diabetes since 5years( was advised medication but did not take and patient made lifestyle changes and dietary changes took guava leaf juice for it) 3months back she got tested and was advised
Glimperide 2mg and metformin 1000mg mrng
And vildagliptin at night .
Now after checking her FBS plbs hb1ac reports
Medications were changed to tab. glimperide 2mg before meals and tab.metformin 500mg after meals.
Patient is k/c/o htn since 5years and is initially tablet telma -am then changed telma 40mg.
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative
No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal
BP- 130/100mmhg
PR -88bpm
RR-19cpm
Spo2 99% at room air
Temperature -98.2f
SYSTEMIC EXAMINATION:
CVS: s1,s2 heard ,no Murmurs,jvp not raised
RS: BAE,no added sounds ,NVBS,
P/A: obese,soft, non tender,bowel sounds can be heard
CNS:
Pt is conscious
Speech is normal
No meningeal signs
Normal cranial nerve examination, motor system, sensory system
GCS: E4,V5,M6
Reflexes:
R L
B ++ ++
T ++ ++
S ++ ++
K ++ ++
A ++ ++
P Flexor Flexor
CLINICAL IMAGES
REPORTS (4/5/2023)
6/5/2023
8/5/2023
PRVISIONAL DIAGNOSIS
KELOID IN THE RIGHT EAR LOBULE S/P INTRALESIONAL STEROID(INJ.KENOCORT 100mg) GIVEN ,WITH RIGHT CHIN SKIN
TAG WITH IRON DEFICIENCY ANEMIA, HTN SINCE 7YEARS AND TYPE2 DIABETES MELLITUS SINCE 5YEARS
TREATMENT GIVEN
1)Tab. MVT PO/OD 2)INJ.KENOCORTINTRALESIONALLY100mg
3)TAB.GLIMIPERIDE 2mg+TAB METFORMIN1000mg PO/OD
4)TAB.TELMA 40MG PO/OD
SUMMARY
DIAGNOSIS: KELOID IN THE RIGHT EAR LOBULE S/P INTRALESIONAL STEROID(INJ.KENOCORT 100mg) GIVEN ,WITH RIGHT CHIN SKIN TAG WITH IRON DEFICIENCY ANEMIA, HTN SINCE 7YEARS AND TYPE2 DM SINCE 5YEARS
HISTORY
CHIEF COMPLAINTS:36yeat old female came with the complaints of lower nack ache and came for keloid removal in right ear lobule
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative
No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema
BP- 110/70mmhg
PR -90bpm
RR-18cpm
Spo2 99% at room air
SYSTEMIC EXAMINATION:
CVS: s1,s2 heard ,no Murmurs,jvp not raised
RS: BAE,no added sounds ,NVBS,
P/A: soft, non tender,bowel sounds can be heard
CNS:
Pt is conscious
Speech is normal
No meningeal signs
Normal cranial nerve examination, motor system, sensory system
GCS: E4,V5,M6
Reflexes:
R L
B ++ ++
T ++ ++
S ++ ++
K ++ ++
A ++ ++
P Flexor Flexor
COURSE AT HOSPITAL
Patient was admitted i/v/o lowerbackache since 1year on and off and for excision of keloid over right ear lobule.
Ortho opinion was taken i/v/o lowerbackache for which they advived NSAID for 1wk
Ent referal was taken i/v/o keloid in the right ear lobule for which intralesional kenocort 100mg inj was given intralesionally and was advised to follow up for serial intralesional injections for which patient and patient attenders wanted to get it done outside (other hospitals).
Obg referral taken i/v/o ammenrrhea since 2months but further investigations and treatment patient refused.
Patient was clinically examined and further investigations for done and was treated conservatively and discharged in stable condition.
ADVICE
1)Tab.MVT PO/OD
2)TAB.GLIMIPERIDE 2mg PO/BD BEFORE MEALS
3)TAB.METFORMIN 500mg PO/BD AFTER MEALS
4)TAB.TELMA 40MG PO/OD
